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Asian Journal of Dental and Health Sciences

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Copyright  © 2024 The   Author(s): This is an open-access article distributed under the terms of the CC BY-NC 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited

 

Addressing Gender-Based Violence to Support HIV Prevention Efforts: A Review

Emmanuel Ifeanyi Obeagu*

Department of Biomedical and Laboratory Science, Africa University, Zimbabwe

 

 

Introduction

Gender-based violence (GBV) is a widespread and deeply entrenched social issue that affects individuals globally, particularly women and marginalized groups. Defined as any harmful act directed at an individual based on their gender, GBV includes physical, sexual, emotional, and psychological violence. The intersection of GBV and HIV is a significant concern in global health efforts, as violence disproportionately affects women, increasing their vulnerability to HIV infection. The global prevalence of both GBV and HIV highlights the need for integrated approaches to address these interrelated public health challenges.¹ Gender-based violence creates an environment in which individuals are more likely to engage in high-risk behaviors, such as unprotected sex or multiple sexual partners, due to coercion or lack of autonomy. These factors significantly increase the risk of HIV transmission. Women, particularly in contexts where they experience economic dependence or limited social power, may be unable to negotiate safer sexual practices or seek out HIV prevention and care services. In such environments, the act of violence itself may lead to physical injuries that make individuals more susceptible to infection, further exacerbating the cycle of risk. The emotional and psychological trauma associated with GBV can also diminish an individual's ability to seek necessary health services, including HIV testing, treatment, and prevention.^2-3

The relationship between GBV and HIV is complex and multifaceted, involving both direct and indirect mechanisms of risk. For instance, survivors of sexual violence may face injuries to their genital tract, which increases the likelihood of HIV transmission if exposed to the virus. Additionally, the long-term psychological effects of violence can contribute to behaviors such as substance abuse, which may impair judgment and lead to increased sexual risk-taking. Moreover, the stigma surrounding both HIV and GBV further complicates the situation, often preventing individuals from accessing essential health services and support. As a result, HIV transmission rates remain disproportionately high among survivors of GBV, particularly in settings where violence is normalized.⁴ The social and structural drivers of GBV, such as gender inequality, power imbalances, and discrimination, are central to understanding its impact on HIV transmission. In many societies, women and girls experience systemic disadvantages that limit their autonomy and agency. These gender norms and practices perpetuate violence and make it difficult for women to access healthcare, education, and other resources that could protect them from HIV. Additionally, cultural beliefs that minimize or normalize violence against women further entrench the cycle of abuse. As these structural factors perpetuate both GBV and HIV, addressing them simultaneously becomes crucial in the effort to reduce new infections and support gender equality.^5-6 Efforts to prevent HIV must take into account the crucial role of gender-based violence. A growing body of research supports the idea that HIV prevention interventions that do not address GBV are likely to be less effective, as violence undermines individuals' ability to take preventive actions, such as practicing safe sex, using HIV prevention tools like pre-exposure prophylaxis (PrEP), or seeking treatment. Conversely, comprehensive approaches that address both HIV and GBV have proven more successful in reducing risk, as they simultaneously tackle the underlying issues of violence and the structural barriers to accessing care. As a result, integrating gender-sensitive strategies into HIV prevention programs is essential for creating sustainable health solutions.^7-8

Understanding the Link between Gender-Based Violence and HIV

The connection between gender-based violence (GBV) and HIV is multifaceted, with GBV acting as both a direct and indirect determinant of HIV risk. GBV exacerbates individuals' vulnerability to HIV through several key mechanisms, including forced or coerced sex, limited negotiation power regarding safe sex, and physical and psychological trauma. As the risk of HIV transmission is strongly influenced by behaviors and access to care, the widespread nature of GBV becomes a critical factor that hinders efforts to prevent the spread of HIV, especially in regions where violence against women and marginalized groups is pervasive.⁹ One of the primary ways in which GBV increases HIV risk is through the practice of coerced or non-consensual sex. Victims of sexual violence, including rape and intimate partner violence, are more likely to be exposed to the virus during these violent acts, particularly if their assailant is HIV-positive. The lack of agency and the inability to negotiate safe sexual practices, such as condom use, further increases the likelihood of HIV transmission. In some cases, survivors of GBV may even be exposed to multiple instances of sexual violence, each increasing their cumulative risk of infection. Furthermore, injuries sustained during violent sexual encounters, such as genital trauma, can provide direct entry points for the HIV virus, raising the physical susceptibility to infection.^10-11

In addition to the direct effects of physical violence, the emotional and psychological impacts of GBV also contribute to heightened HIV risk. Survivors of GBV often experience trauma that can manifest in depression, anxiety, and post-traumatic stress disorder (PTSD), which may lead to risky behaviors such as substance abuse and sexual risk-taking. These emotional burdens may impair a person’s ability to take preventive actions, such as using condoms or accessing HIV care, because their emotional well-being and decision-making capacity may be compromised. Furthermore, the stigma associated with both GBV and HIV often leads to isolation and a lack of support, preventing individuals from seeking help or disclosing their experiences to healthcare providers.¹² Another key aspect of the link between GBV and HIV is the influence of gender inequality and power dynamics within relationships. In societies where women and girls are socially and economically disadvantaged, they are often less able to negotiate sexual practices or leave abusive relationships. Gender norms that condone male dominance and female submission further exacerbate this issue. In these settings, women may feel unable to refuse sex or insist on protective measures, leaving them vulnerable to HIV exposure. The pervasive nature of these gender inequalities means that GBV is not only a consequence of sexual violence but also a manifestation of broader societal structures that perpetuate both violence and vulnerability to HIV.¹³

Moreover, the broader societal consequences of GBV often lead to limited access to essential HIV services. Victims of GBV, particularly women, may face multiple barriers to seeking healthcare, including fear of further abuse, lack of financial resources, and stigma from both their communities and healthcare providers. In many settings, survivors may be reluctant to disclose their experiences for fear of being blamed or judged. This reluctance to seek care can delay HIV diagnosis, treatment, and prevention, leading to worse health outcomes. Additionally, in cases where individuals are subjected to repeated violence, there may be chronic exposure to high-risk situations, increasing their lifetime risk of HIV infection.^14-15 The link between GBV and HIV also highlights the importance of integrated approaches to prevention. Traditional HIV prevention efforts, such as condom distribution or PrEP programs, can be significantly less effective if they do not account for the presence of GBV. Programs that address both violence and HIV in a holistic manner, offering support to survivors of violence while also promoting safe sexual practices, are likely to be more successful. These programs must take a multi-sectoral approach, involving not only healthcare providers but also legal systems, community leaders, and education systems to challenge harmful gender norms and ensure that survivors have access to the resources they need to break free from the cycle of violence and risk.^16-17 Ultimately, the link between GBV and HIV underscores the importance of addressing gender inequality as a fundamental strategy in HIV prevention. Reducing violence against women and marginalized populations, empowering individuals to assert their rights, and providing comprehensive care for those affected by GBV can help reduce HIV transmission. This interconnected approach to GBV and HIV prevention is not only essential for improving health outcomes but also for promoting gender equality and fostering safer, healthier communities.¹⁸

Impact of Gender Inequality on HIV Risk

Gender inequality plays a critical role in increasing vulnerability to HIV infection, particularly among women and marginalized groups. In many societies, women and girls experience systemic disadvantages that limit their ability to protect themselves from HIV. These inequalities are often manifested in various aspects of life, including economic dependence, limited access to education, cultural norms, and social expectations, all of which contribute to a higher risk of HIV transmission. By understanding the impact of gender inequality on HIV risk, we can better develop interventions that address the root causes of this vulnerability and help reduce new infections.¹⁹ One of the primary ways in which gender inequality increases HIV risk is through the imbalance of power in sexual relationships. In many societies, women and girls are socialized to be submissive to male partners, which can hinder their ability to negotiate safer sex practices, such as condom use. The inability to refuse sex or insist on protective measures makes women more susceptible to HIV exposure, particularly in situations where their partners may have multiple sexual partners or be at risk of infection themselves. In some regions, the gendered expectation that women should prioritize their partner's desires over their own sexual health needs perpetuates this power dynamic, limiting their ability to protect themselves from HIV.²⁰

Economic dependence is another key factor that exacerbates HIV risk among women. In many societies, women are financially dependent on men, which can create a barrier to leaving unsafe relationships or seeking healthcare. Economic vulnerability increases the likelihood that women will stay in abusive or high-risk situations, including relationships where their partners may refuse to use protection or engage in risky sexual behaviors. This financial dependency also limits women's ability to access HIV prevention tools, such as pre-exposure prophylaxis (PrEP), or attend regular health checkups. When women lack financial independence, they may be less empowered to assert their health and sexual rights, further increasing their susceptibility to HIV.²¹ Cultural norms and social expectations also play a significant role in shaping gender inequality and HIV risk. In many cultures, traditional gender roles place women in a subordinate position, which can normalize gender-based violence (GBV) and exacerbate their vulnerability to HIV. For example, women who experience intimate partner violence or sexual violence are at a higher risk of HIV infection, as violence often includes coerced or non-consensual sex. Additionally, the stigma surrounding HIV and gender-based violence may prevent women from disclosing their status, seeking treatment, or accessing preventative care. Women who are blamed for their own exposure to violence or HIV are less likely to receive the care and support they need, which perpetuates the cycle of risk.²²

The impact of gender inequality on HIV risk is also magnified by the intersectionality of other forms of discrimination, such as race, class, and sexual orientation. Women and girls who belong to marginalized communities, including ethnic minorities, refugees, and members of the LGBTQ+ community, face compounded risks due to social stigma and discrimination. These individuals often have less access to healthcare services, face greater barriers to education, and may experience higher levels of violence. For example, LGBTQ+ women and men who have sex with men (MSM) are more likely to face discrimination in healthcare settings, which may discourage them from seeking HIV testing, treatment, or prevention services. Addressing HIV risk in these populations requires acknowledging and combating multiple forms of inequality.²³ Reducing gender inequality is therefore essential in mitigating HIV risk. Interventions that empower women and marginalized groups, improve economic independence, and promote gender equality can significantly reduce the vulnerability to HIV. Programs that focus on changing harmful gender norms, such as promoting mutual respect and consent in relationships, are essential in fostering safer sexual practices and improving HIV prevention efforts. Furthermore, strengthening access to sexual and reproductive health services, including HIV testing, prevention, and treatment, is crucial in ensuring that individuals have the tools and support they need to protect themselves. Legal reforms that protect women from violence and discrimination also play a critical role in reducing the intersectional risks that contribute to the spread of HIV.²⁴

Gender-Sensitive HIV Prevention Strategies

Gender-sensitive HIV prevention strategies are essential for addressing the unique needs and vulnerabilities of individuals, particularly women and marginalized groups, who face disproportionate risks of HIV infection due to gender inequality, social norms, and violence. These strategies recognize that gender-based violence (GBV), gender inequality, and societal power dynamics significantly influence HIV transmission and the ability to access care. Effective gender-sensitive approaches go beyond general HIV prevention methods by integrating gender-specific interventions that empower individuals, challenge harmful gender norms, and address the structural and social barriers to HIV prevention.²⁵ One key gender-sensitive strategy involves promoting women's empowerment and improving their autonomy in sexual relationships. In many contexts, women face social and cultural constraints that limit their ability to negotiate safer sex practices, such as condom use, or to refuse sexual activity altogether. Empowering women to make decisions about their sexual health is crucial for reducing HIV risk. This includes providing education on sexual and reproductive rights, promoting self-efficacy in negotiating safer sex, and increasing access to HIV prevention tools like pre-exposure prophylaxis (PrEP) and condoms. Programs that focus on increasing women's agency in both sexual and economic spheres can lead to healthier decision-making, as women are more likely to take preventive actions when they have control over their sexual and financial choices.²⁶

Addressing gender-based violence (GBV) through integrated HIV prevention strategies is another critical component of gender-sensitive approaches. GBV, particularly intimate partner violence and sexual violence, increases the risk of HIV transmission by undermining a person’s ability to protect themselves from infection. Gender-sensitive HIV prevention programs must incorporate support services for GBV survivors, such as legal assistance, mental health care, and access to post-rape care. These programs should provide education and resources for both men and women to challenge harmful gender norms that perpetuate violence, promote healthy relationship dynamics, and ensure that survivors of violence can seek timely HIV testing, care, and treatment. Incorporating GBV prevention into HIV strategies helps break the cycle of violence and infection, reducing overall HIV risk within communities.²⁷ Access to gender-responsive healthcare services is essential in ensuring that individuals, particularly women, can benefit from HIV prevention and care programs. Gender-sensitive healthcare goes beyond the provision of HIV testing and treatment by addressing the specific barriers that women and marginalized groups face in accessing services. For instance, in many settings, women experience challenges in accessing HIV prevention tools, including PrEP, due to societal stigma or logistical barriers such as lack of privacy, transportation, or financial resources. Health providers must be trained to offer non-judgmental, gender-sensitive care, ensuring that women feel safe and supported in accessing HIV prevention services. Programs that offer integrated sexual and reproductive health services, including family planning, maternal health, and HIV prevention, are critical in addressing the diverse needs of individuals.²⁸

Incorporating a focus on adolescent girls and young women is a particularly important aspect of gender-sensitive HIV prevention strategies. This group faces a heightened vulnerability to HIV due to a combination of biological, social, and cultural factors. Adolescent girls may lack the knowledge, confidence, or agency to protect themselves from HIV, and they may also experience higher rates of sexual violence or coerced sex. Gender-sensitive programs aimed at young people should prioritize sexual education, safe spaces, and peer support, as well as ensuring access to HIV prevention tools like condoms and PrEP. Programs that engage both young women and young men in conversations about consent, gender norms, and healthy relationships can foster a more equitable environment, where both genders share responsibility for preventing HIV.²⁹ Finally, addressing the intersectional vulnerabilities faced by marginalized groups is an essential aspect of gender-sensitive HIV prevention. These groups, including LGBTQ+ individuals, sex workers, and people who inject drugs, experience compounded risks due to intersecting forms of discrimination, social exclusion, and violence. HIV prevention strategies must be tailored to the unique needs of these populations, recognizing their specific risks and barriers to accessing care. Providing safe, confidential spaces for marginalized groups to access HIV testing, prevention, and treatment services is crucial for ensuring that these individuals are not left behind in the fight against HIV. Legal protections, social support networks, and community-led advocacy efforts can also play a vital role in reducing the stigma and discrimination that contribute to higher HIV risk in these groups.³⁰

Challenges and Limitations

While gender-sensitive HIV prevention strategies are essential in addressing the unique vulnerabilities and needs of women and marginalized groups, their implementation and effectiveness face several significant challenges. These challenges stem from structural, cultural, and economic barriers, as well as the deeply entrenched gender norms and inequalities that continue to shape societal attitudes towards HIV, gender, and sexual health. Understanding these challenges is crucial for improving the design, scale, and impact of gender-sensitive interventions, ensuring that they can effectively reduce HIV risk and address the root causes of gender inequality.³¹ One of the primary challenges in implementing gender-sensitive HIV prevention strategies is the persistence of harmful gender norms and stereotypes. In many societies, traditional views about gender roles and sexuality often create barriers for women and marginalized groups to negotiate safer sex or to seek HIV prevention services. For example, the belief that women should be passive in sexual relationships or that men must be the primary decision-makers can prevent women from asserting their rights or negotiating condom use. These entrenched societal expectations make it difficult for gender-sensitive programs to achieve meaningful change, as they require not only changing individual behaviors but also transforming deep-seated cultural attitudes and norms. Overcoming these barriers requires long-term efforts that involve community engagement, education, and the active participation of both men and women in redefining gender roles and expectations.³²

Another limitation of gender-sensitive HIV prevention strategies is the challenge of addressing the intersectionality of risks faced by women and marginalized groups. Many individuals experience compounded vulnerabilities due to the overlap of gender with other forms of discrimination, such as race, class, sexual orientation, and disability. For example, Black and Indigenous women, as well as LGBTQ+ individuals, may face higher levels of violence, discrimination, and limited access to healthcare services compared to their peers. These intersecting forms of marginalization can make it more difficult for gender-sensitive HIV prevention strategies to effectively reach and support the most at-risk populations. Tailoring interventions to address these diverse experiences requires a nuanced understanding of intersectionality and the development of programs that are culturally appropriate, inclusive, and flexible enough to meet the complex needs of different groups. However, achieving this level of specificity and inclusivity can be resource-intensive and may require significant investment in community-led programs and localized research.³³ Economic barriers also play a crucial role in limiting the effectiveness of gender-sensitive HIV prevention strategies. In many low- and middle-income countries, women and marginalized groups face economic dependency, which can restrict their ability to access HIV prevention tools, services, or educational resources. Financial constraints can prevent women from seeking HIV testing, accessing PrEP, or participating in HIV prevention programs. For example, in some settings, women may be unable to afford transportation to health clinics, or may face the risk of financial exploitation by male partners or family members who control household finances. Additionally, poverty can increase vulnerability to gender-based violence (GBV), as women may feel pressured to stay in abusive relationships due to economic dependency. Gender-sensitive strategies must address these economic disparities by offering financial support, subsidies, or accessible healthcare options. Without addressing the broader economic context, these interventions may fail to reach the individuals most in need of HIV prevention services.³⁰

Cultural and legal barriers further complicate the implementation of gender-sensitive HIV prevention strategies. In many societies, laws and policies related to gender, sexual health, and HIV prevention may not be supportive of the needs of women and marginalized groups. For example, laws that criminalize same-sex relationships, sex work, or drug use can create environments of fear and stigma, preventing individuals from accessing HIV prevention services. Additionally, the lack of legal protections for women experiencing intimate partner violence or sexual harassment can discourage them from seeking help or reporting abuse. Cultural taboos surrounding discussions of sex, HIV, and gender-based violence can also prevent open dialogue and awareness campaigns, leaving many individuals unaware of their rights or available services. To overcome these challenges, gender-sensitive HIV prevention strategies must be accompanied by advocacy for legal reforms and policies that protect human rights and reduce stigma and discrimination.³¹

Lastly, the limited availability of gender-sensitive healthcare services poses another significant challenge. In many regions, healthcare systems are not equipped to provide the necessary support for women, LGBTQ+ individuals, or other marginalized groups in a safe and non-judgmental manner. Health providers may lack training on gender sensitivity or may perpetuate stigma themselves, creating an environment where individuals feel unsafe or uncomfortable seeking care. Moreover, HIV services may be siloed from other health services, such as sexual and reproductive health or mental health, which are essential for addressing the full spectrum of needs for women and marginalized groups. Integrating gender-sensitive care into broader healthcare systems requires training healthcare professionals, creating gender-responsive service delivery models, and ensuring that services are accessible and non-stigmatizing.^32-33

Conclusion

Gender-sensitive HIV prevention strategies are critical in addressing the disproportionate burden of HIV on women and marginalized populations, particularly those who are at the intersection of gender-based violence, social inequities, and discrimination. These strategies recognize that gender inequality and harmful societal norms significantly contribute to the vulnerability of individuals to HIV, and therefore, must be an integral part of the global HIV response. By empowering individuals to make informed decisions about their sexual health, challenging harmful gender norms, and providing comprehensive support for survivors of gender-based violence, these strategies can significantly reduce HIV transmission and promote healthier outcomes.

Conflict of Interest: Author declares no potential conflict of interest with respect to the contents, authorship, and/or publication of this article.

Source of Support: Nil

Funding: The authors declared that this study has received no financial support.

Informed Consent Statement: Not applicable. 

Data Availability Statement: The data supporting in this paper are available in the cited references. 

Ethics approval: Not applicable.

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